Potentially Preventable Medicare Spending High in Frail Elderly

Diana Phillips

October 19, 2017

Frail elderly adults account for the majority of potentially preventable spending among Medicare beneficiaries, a study has shown.

In an analysis of Medicare beneficiaries in the top 10% of individual spending in 2012, adults aged 65 years or older with two or more conditions, which is considered to indicate frailty, accounted for nearly 44% of spending deemed potentially preventable despite making up only 4% of the population sample, researchers found. Jose F. Figueroa, MD, MPH, from the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and colleagues report their findings in an article published online October 17 in the Annals of Internal Medicine.

Using a 20% sample of Medicare fee-for-service claims from 2012 representing 6,112,450 beneficiaries, the researchers identified the degree to which beneficiaries in each of six mutually exclusive, high-cost subpopulations (nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy) accounted for potentially preventable spending. Such spending was determined based on potentially preventable hospitalizations, emergency department visits, and postacute costs.

Of the six subopulations, the high-cost frail elderly patients had the highest mean per patient potentially preventable costs, at $6593, followed by $3421 for high-cost nonelderly disabled beneficiaries, $3327 in high-cost major complex beneficiaries (those with two or more complex conditions or at least six noncomplex conditions), $1805 in the high-cost minor complex beneficiaries (one complex condition or fewer than six noncomplex conditions), $1356 in the high-cost relatively healthy, and $771 in the high-cost simple chronic beneficiaries (one to five noncomplex conditions), the authors report.

The same pattern emerged across the six patient segments in an analysis of the full population. Frail elderly beneficiaries accounted for 8.6% of the population but more than 51% of potentially preventable spending, the authors note.

Most of the potentially preventable spending for high-cost frail elderly patients was for care received in the inpatient setting ($3164 per person) or in skilled-nursing facilities ($1917), and much of it was for acute care visits for heart failure ($451), bacterial pneumonia ($355), urinary tract infections ($289), diabetes long-term complications ($152), and dehydration ($121), the authors report.

Potentially preventable inpatient spending for the high-cost nonelderly disabled group and the major complex chronic group was $2128 and $1960, respectively.

Given that the high-cost frail elderly group accounted for almost half of all potentially preventable spending after admissions for ambulatory care sensitive conditions or potentially avoidable emergency department visits, targeting interventions to this population may help reduce healthcare costs, the authors note.

"Our work suggests that simple interventions in the outpatient setting, such as close management of heart failure and prevention of urinary tract infections, may substantially reduce unnecessary spending," they write.

The findings also point to the need for a greater understanding of the health consequences of frailty, "especially as the U.S. population ages and frailty becomes more prevalent," the authors write. They note that this study adds to a growing body of literature linking frailty to clinical outcomes and costs.

In a recent study reported by Medscape Medical News, physical frailty was associated with a greater risk for complications after common ambulatory surgery than increasing chronological age.

Segmenting patient populations to more clearly identify and target groups for interventions "is especially relevant as we continue to shift accountability for costs and outcomes to health care providers under [the Medicare Access and CHIP Reauthorization Act of 2015] and through programs like accountable care organizations, which directly include quality measures of [ambulatory care sensitive conditions]," the authors write.

Bruce Leff, MD, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and Arnold Milstein, MD, from Stanford University School of Medicine Clinical Excellence Research Center, California, agree with this assessment. Based on MACRA, they write in an accompanying editorial, "Medicare payment incentives for physicians to improve the value of health care are ascending toward maximum adjustments in 2022. With this shift, greater attention will be paid to mitigating the danger and cost of health crises for high-need, high-cost older adults." This shift will also require new data collection and analysis, treatment planning that focuses on the social determinants of health and patient functional status, and new payment and patient assignment models.

The current study "can help point the way to 'coolable' hot spots," according to the editorial authors. "The onus is now on organizations and systems to shift culture and learn to implement the care and contracting methods used by their 'coolest' peers."

Funding for this study was provided by the Commonwealth Fund. Dr Figueroa reports receiving grants from the Commonwealth Fund during the conduct of the study. The other authors and the editorialists have disclosed no relevant financial relationships.

Ann Intern Med. Published online October 17, 2017. Article abstract, Editorial extract

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